Release text

To: PillHelp®,Company LLC a.k.a. pillhelp.com (Insert custom company name), Physicians, Health Care Providers, Pharmacies and Insurance Providers which have served me,

Name:	   	Charlene Nells	
Address:	   	Box 3590 Exeter Road
Stetson, ME 04488	
You are hereby authorized to share my medical and/or pharmaceutical information and/or records with each other. The information and/or records requested and provided may cover findings, treatments rendered and opinions about my medical condition.
PillHelp®,Company LLC a.k.a. pillhelp.com  (Insert custom company name) is hereby authorized to provide my medical insurer(s) with information required for payment of services received from PillHelp®  (Insert custom company name) further will strive to provide adequate yet minimal information to insurers.
I hereby waive any privilege of medical confidentiality I have between you so that you may communicate with each other.
The foregoing authority shall continue in force until revoked by me in writing received by PillHelp®,Company LLC  (Insert custom company name).
A photocopy or facsimile (FAX) copy of this Authorization may be used in lieu of the signed original.